{"id":1198,"date":"2016-10-16T17:26:00","date_gmt":"2016-10-17T00:26:00","guid":{"rendered":"http:\/\/blog.stevenreidbordmd.com\/?p=1198"},"modified":"2016-10-18T19:55:27","modified_gmt":"2016-10-19T02:55:27","slug":"prescription-drug-abuse-and-the-physician-gatekeeper","status":"publish","type":"post","link":"http:\/\/blog.stevenreidbordmd.com\/?p=1198","title":{"rendered":"Prescription drug abuse and the physician gatekeeper"},"content":{"rendered":"

\"guard-gate\"<\/a>Opioid painkillers such as Vicodin (hydrocodone) and OxyContin (oxycodone)\u00a0are crucial medical tools\u00a0that\u00a0are addictive and widely\u00a0abused. \u00a0Tranquilizers and sleeping pills of the benzodiazepine class, e.g., Xanax (alprazolam), Ativan (lorazepam), and Klonopin (clonazepam), are safe and effective in limited, short-term use, but are often\u00a0taken too freely, leading to drug tolerance and\u00a0withdrawal risks. \u00a0Stimulants such as\u00a0Ritalin (methylphenidate) and Adderall (amphetamine) ease the burden of ADHD, but are also widely used<\/a> as college study aids as well as\u00a0recreationally. \u00a0All of these medications are available only by prescription. \u00a0This means prescribers serve as gatekeepers<\/a>, permitting access for\u00a0medical\u00a0needs and\u00a0denying it\u00a0otherwise.<\/p>\n

This gatekeeping can be\u00a0difficult. \u00a0Doctors are imperfect\u00a0lie detectors\u00a0and\u00a0can be fooled with\u00a0a plausible story. \u00a0Pain, anxiety, insomnia, and inattention are mostly invisible.\u00a0 The internet offers quick lessons\u00a0in\u00a0how to fake a medical history. \u00a0Beyond the initial assessment, every physician has patients who repeatedly “lose” bottles of painkillers or tranquilizers and request more. \u00a0Secretly seeing multiple doctors to obtain\u00a0the same drug remains\u00a0fairly easy. \u00a0While a few doctors run illegal “pill mills” and flout\u00a0the gatekeeper role, many more\u00a0are simply too overworked\u00a0to be\u00a0vigilant with every patient.<\/p>\n

None\u00a0of us\u00a0became physicians to fight\u00a0the war on drugs. \u00a0On the contrary, most of us are\u00a0uncomfortable doubting\u00a0our patients’ honesty. \u00a0It’s stressful to worry\u00a0about\u00a0being too suspicious or\u00a0too gullible, and it’s a waste of valuable\u00a0time.<\/p>\n

The possibility of tranquilizer\u00a0abuse arose with a new patient of mine recently. \u00a0My concern\u00a0led to\u00a0multiple phone calls to pharmacies\u00a0and to consulting California’s\u00a0CURES database<\/a> online. \u00a0I was convinced enough that\u00a0something was amiss that I confronted my\u00a0patient, who responded by calling me names, making vague threats, and leaving in a huff without paying for the appointment (and, of course, never coming back). \u00a0Although the reaction seemed confirmatory, in\u00a0truth I’m still not certain\u00a0my suspicions were\u00a0correct. \u00a0Why did I put my patient and myself through such grief? \u00a0Because I wanted to “do no harm.” \u00a0Accepting the gatekeeper role requires\u00a0scrutinizing and sometimes confronting\u00a0the patient at the gate.<\/p>\n

Let’s consider other drugs that are used\u00a0both medically and recreationally\u00a0\u2014 but unlike those mentioned above, do not involve a\u00a0physician gatekeeper.<\/p>\n

The best candidate may be cannabis. \u00a0Currently\u00a0legal in 25<\/a>\u00a0states, medical marijuana requires a doctor’s authorization but not a prescription that specifies\u00a0dosage, frequency, duration of treatment, or route of administration. \u00a0By definition,\u00a0a Schedule I drug like marijuana is not “FDA approved” for any medical use. \u00a0Yet cannabis is very much like the Schedule II drug Adderall: it has a few\u00a0solid<\/a>\u00a0medical uses, a much larger set<\/a> of dubious\u00a0or\u00a0controversial\u00a0ones, and a vast sea of mostly illegal recreational use. \u00a0A lot of\u00a0medical marijuana is used for relaxation or sleep, blurring the medical-recreational distinction in much the way Adderall does when used for studying. \u00a0Purely recreational use is legal in four states as of this writing. \u00a0Legalization is on the ballot this November in five<\/a> additional states, including California where I practice.<\/p>\n

I have never authorized medical marijuana, although several\u00a0of my patients were\u00a0approved by other physicians and use it regularly. \u00a0Once a patient tells me he or she uses marijuana, whether doctor-approved or (for now) illegally, I can act in my preferred role as advisor. \u00a0We can discuss risks\u00a0and benefits, sativa versus indica, THC and CBD, all without me having to second-guess my patient’s story, make a paternalistic\u00a0decision about whether to authorize access, or even cast judgment on\u00a0the decision to use it.<\/p>\n

In states where recreational cannabis is newly legal, it joins the three drugs already native to\u00a0our\u00a0cultural landscape. \u00a0Adults consume\u00a0alcohol, caffeine, and nicotine with\u00a0nary\u00a0a prescription, gatekeeper, or hoop to jump through. \u00a0And although we rarely\u00a0think about it,\u00a0all three have medicinal effects. \u00a0Alcohol can reduce stress, aid sleep, and may<\/a>\u00a0promote health in a number\u00a0of other ways.\u00a0 Caffeine treats<\/a>\u00a0fatigue, migraine headaches, and possibly obesity. \u00a0Nicotine eases<\/a>\u00a0Parkinson’s disease and perhaps schizophrenia, and helps with weight loss. \u00a0While smoking rates are\u00a0declining<\/a> in the U.S., most Americans\u00a0continue to use alcohol<\/a> and caffeine<\/a>\u00a0often and for a complex mixture of reasons:\u00a0taste, psychoactive effects, social custom, and sometimes for plainly\u00a0medicinal purposes. \u00a0Widespread use also leads to\u00a0addiction in a significant subset of the population: caffeine becomes necessary and not just optional, and we go to extraordinary efforts to manage alcoholism. \u00a0As tragic as this is, nearly everyone agrees that Prohibition was the greater\u00a0evil.<\/p>\n

I\u00a0like that I’m\u00a0an advisor, not a\u00a0gatekeeper,\u00a0for marijuana and the (other) legal vices. \u00a0I also reject\u00a0the gatekeeper\u00a0role for\u00a0stimulants by telling callers I don’t treat ADHD<\/a>. \u00a0This is trickier: my refusal to treat a\u00a0legitimate\u00a0psychiatric disorder\u00a0is arguably\u00a0too finicky. \u00a0It can be hard for an earnest sufferer to obtain\u00a0a thorough evaluation and treatment, even if paradoxically<\/a>\u00a0it is all too easy for a drug abuser to tell a sob story and score\u00a0a prescription. \u00a0Nonetheless, with stimulants as with medical marijuana, I’m uncomfortable making Solomonic distinctions where medical and non-medical uses lie\u00a0so closely\u00a0on a continuum.<\/p>\n

In any event, I draw the line there. \u00a0I continue to prescribe\u00a0tranquilizers and\u00a0sleeping pills\u00a0for my patients who seem to need them. \u00a0I may unwittingly abet\u00a0substance abuse in some cases, but the alternative is to not\u00a0prescribe any abusable medication, a stance that feels far too finicky. \u00a0After all, medication\u00a0gatekeeping is the norm\u00a0for many physicians. \u00a0Oncologists, surgeons, and ER doctors can’t tell\u00a0patients they don’t treat pain. \u00a0Surgeon general Vivek Murthy sent a letter<\/a> to every U.S. physician in August urging us\u00a0to help fight the “opioid epidemic” by limiting dosages\u00a0and\u00a0durations of opioid prescriptions, and by substituting non-narcotic alternatives \u2014 in essence, by being better gatekeepers.<\/p>\n

The only way to avoid doctor-as-gatekeeper entirely is to make all drugs available without a prescription. \u00a0The prospect\u00a0of narcotics\u00a0and amphetamines on the open market strikes most of us\u00a0as extremely foolish, even though\u00a0Prohibition and the failed war on drugs should give us pause.\u00a0The other strategy is to embrace gatekeeping\u00a0even more seriously,\u00a0as Dr. Murthy advises. \u00a0Careful comprehensive evaluation, “start low and go slow” prescribing, close monitoring using a system like CURES, and strictly limiting refills should drive down prescription drug abuse. \u00a0Unfortunately, this takes more clinical time, one\u00a0thing most physicians can’t spare, and a trading away of doctor-patient collaboration\u00a0for something more wary and legalistic. \u00a0As usual, physicians are\u00a0asked to erode\u00a0the traditional doctor-patient relationship, and do more work,\u00a0to\u00a0keep the system afloat. \u00a0Meanwhile, patients suffer further small indignities and a colder encounter.<\/p>\n

Alternatively,\u00a0we could wait it out. \u00a0The line between medical treatment and personal enhancement or optimization gets fuzzier all the time. \u00a0Society may soon fail to\u00a0distinguish treating an anxiety disorder and\u00a0taking something to relax in the evening, or treating ADHD and\u00a0simply maximizing one’s\u00a0mental\u00a0sharpness. \u00a0The medical-recreational divide already looks more like\u00a0a continuum\u00a0for marijuana and stimulants, and is essentially gone with respect to\u00a0alcohol, caffeine, and nicotine. \u00a0If this trend continues, physicians may\u00a0no longer be called upon to distinguish legitimate from illegitimate drug use. \u00a0Our focus as medication gatekeepers may\u00a0shift from the purpose of the prescription to its safety, making us more like pharmacists than judges.<\/p>\n","protected":false},"excerpt":{"rendered":"

Opioid painkillers such as Vicodin (hydrocodone) and OxyContin (oxycodone) are crucial medical tools that are addictive and widely abused. Tranquilizers and sleeping pills of the benzodiazepine class, e.g., Xanax (alprazolam), Ativan (lorazepam), and Klonopin (clonazepam), are safe and effective in limited, short-term use, but are often taken too freely, leading to drug tolerance and withdrawal […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"categories":[4,67],"tags":[26,76,27],"class_list":["post-1198","post","type-post","status-publish","format-standard","hentry","category-current-events","category-medical-practice","tag-adhd","tag-marijuana","tag-stimulants","odd"],"aioseo_notices":[],"_links":{"self":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts\/1198","targetHints":{"allow":["GET"]}}],"collection":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=1198"}],"version-history":[{"count":8,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts\/1198\/revisions"}],"predecessor-version":[{"id":1208,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts\/1198\/revisions\/1208"}],"wp:attachment":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=1198"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=1198"},{"taxonomy":"post_tag","embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=1198"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}